Peritonsillar Abscess in Saudi Arabia: Symptoms, Causes & Treatment | aihealz
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Peritonsillar Abscess.Care & specialists in Saudi Arabia
In Saudi Arabia, peritonsillar Abscess is managed by ents. A peritonsillar abscess, known historically as quinsy, is a localized collection of pus between the palatine tonsil capsule and the superior pharyngeal constrictor muscle, most often caused by spread of bacterial tonsillitis into the surrounding soft tissue. It is the most common deep-neck-space infection in adolescents and young adults, with an incidence of roughly 30-37 cases per 100,000 person-years in industrialized countries.
Peritonsillar abscess (ICD-10: J36) is a suppurative collection in the peritonsillar space — the loose connective-tissue plane between the lateral aspect of the palatine tonsil capsule and the superior pharyngeal constrictor muscle. The infection most often arises as a complication of acute exudative tonsillitis when bacterial spread crosses the tonsillar capsule, but can also originate from the supratonsillar minor salivary glands (Weber glands), explaining cases without preceding tonsillitis. Microbiology is mixed: predominant organisms are Streptococcus pyogenes (group A streptococcus, in 30-50%), Streptococcus anginosus group, Fusobacterium necrophorum, Prevotella, Peptostreptococcus, and Staphylococcus aureus including MRSA. The abscess is supero-lateral to the tonsil in 90% of cases, but inferior pole abscesses occur.
key facts
Prevalence
30-37 per 100,000 person-years (industrialized countries); peak incidence in adolescents and young adults
Demographics
Most common ages 15-30; smokers, men, and patients with recurrent tonsillitis at elevated risk; incidence rises in winter
Avg. age
Median age 20-25 years; uncommon under age 5 and over 60
Global cases
Approximately 45,000 cases annually in the United States (NEDS), with bilateral abscess in 5-7%
Specialist
ENT
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How you might notice it
The key symptoms of Peritonsillar Abscess are: Severe one-sided sore throat that worsens progressively over 2-4 days and is poorly relieved by simple analgesia., Painful and limited mouth opening (trismus) with an interincisor distance often under 2 cm — a hallmark feature., Muffled hot-potato voice from soft palate swelling, distinguishable from the hoarseness of laryngitis., Drooling and pooling of saliva because swallowing is too painful to maintain, with weight loss and dehydration over 24-48 hours., Ipsilateral referred earache (otalgia) from glossopharyngeal nerve involvement., Fever, usually 38.5-40 °C, with rigors, myalgia, and malaise., Swollen, tender cervical lymphadenopathy, especially in the jugulodigastric chain on the affected side..
01Severe one-sided sore throat that worsens progressively over 2-4 days and is poorly relieved by simple analgesia.
02Painful and limited mouth opening (trismus) with an interincisor distance often under 2 cm — a hallmark feature.
03Muffled hot-potato voice from soft palate swelling, distinguishable from the hoarseness of laryngitis.
04Drooling and pooling of saliva because swallowing is too painful to maintain, with weight loss and dehydration over 24-48 hours.
05Ipsilateral referred earache (otalgia) from glossopharyngeal nerve involvement.
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How it’s diagnosed
diagnosis
Diagnosis is largely clinical. The combination of severe unilateral sore throat, trismus, hot-potato voice, drooling, fever, and a bulging soft palate with contralateral uvular deviation is highly specific. Examination begins with vital signs (fever, tachycardia, blood pressure), assessment of mouth opening (interincisor distance), airway patency, and inspection of the oropharynx using a tongue depressor and headlight. Trismus often limits direct visualization; intraoral ultrasound at the bedside, transcutaneous ultrasound, or contrast-enhanced CT of the neck differentiates abscess from cellulitis when examination is non-diagnostic or deep-neck-space extension is suspected. Bloodwork shows leukocytosis with neutrophilia, raised C-reactive protein, and sometimes electrolyte derangement from poor fluid intake. Throat swab for rapid streptococcal antigen and culture is taken when feasible. Diagnostic and therapeutic needle aspiration with a 16-18G needle, after topical lignocaine spray, confirms the diagnosis by aspirating pus and decompresses the abscess in a single step. Aspirate is sent for Gram stain, aerobic and anaerobic culture. CT imaging is reserved for patients in whom direct examination is impossible (severe trismus), bilateral abscess is suspected, the abscess fails to resolve, deep-neck extension is suspected, or recurrent presentation. Lemierre syndrome should be considered when high fever and rigors persist after drainage; CT of the neck with contrast and blood cultures identify internal jugular vein thrombophlebitis. Differential diagnosis includes peritonsillar cellulitis, infectious mononucleosis with massive tonsillar swelling, parapharyngeal abscess, dental abscess, and tonsillar lymphoma in patients with persistent unilateral tonsil enlargement.
Bedside needle aspirationConfirms abscess by aspirating pus, decompresses the collection, and obtains material for culture
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Treatment & cost
medical treatments
✓Intravenous amoxicillin-clavulanate (1.2 g 8-hourly)
✓Intravenous clindamycin (600 mg 6-hourly)
✓Intravenous benzylpenicillin plus metronidazole
✓Dexamethasone 8-10 mg IV (one or two doses)
surgical options
Needle aspiration (16-18G)Single-attempt resolution in 87-94% of cases; second aspiration succeeds in most remaining patients
Incision and drainage92-95% resolution in pooled meta-analyses; slightly higher than needle aspiration
Quinsy tonsillectomy (immediate)Cure rate over 99% with single procedure; bleeding complication rate 3-5%
Interval tonsillectomyPrevents recurrent peritonsillar abscess in over 95% of patients
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Causes & risk factors
known causes
Spread of acute bacterial tonsillitis
Most cases arise as a complication of streptococcal or polymicrobial tonsillitis. Bacteria penetrate the tonsillar capsule and seed the loose peritonsillar tissue, where they multiply unchecked. Roughly 70% of patients with peritonsillar abscess have a preceding sore throat illness.
Infection of Weber glands
Small mucous salivary glands in the supratonsillar fossa (Weber glands) can become obstructed and infected, producing abscess without prior tonsillitis. This explains the 20-30% of patients who present without a recent sore throat.
Polymicrobial aerobic and anaerobic infection
Cultures typically grow group A Streptococcus, Streptococcus anginosus group, Fusobacterium necrophorum, Prevotella, Peptostreptococcus, and occasionally Staphylococcus aureus (including MRSA). Anaerobes are present in 50-60% of cases and explain the characteristic halitosis.
Smoking
Cigarette smoking impairs mucosal immunity and alters oropharyngeal flora; smokers have roughly 3-4× higher incidence of peritonsillar abscess than non-smokers in case-control studies.
Untreated or inadequately treated tonsillitis
Inadequate antibiotic course, poor adherence, or initial misdiagnosis of viral pharyngitis allows bacterial proliferation. Patients who stop antibiotics early after symptomatic improvement have elevated risk.
Dental and gingival infection
Periapical abscess and severe periodontitis can spread to the peritonsillar space through lymphatics or direct extension, particularly in immunocompromised patients.
risk factors
Age 15-30 years
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Living with it
01Treat bacterial tonsillitis with a full 10-day course of penicillin or amoxicillin to eradicate group A Streptococcus.
02Avoid smoking and reduce alcohol consumption to lower mucosal vulnerability.
03Maintain dental hygiene with regular brushing, flossing, and dental review every 6-12 months.
04Discuss interval tonsillectomy with an ENT surgeon after a first episode of peritonsillar abscess, especially in patients with recurrent tonsillitis.
05Practice good hand hygiene during winter months to reduce respiratory infection transmission.
06Seek prompt medical review for sore throat lasting more than 5 days or worsening despite treatment.
recommended foods
•Cool soft foods such as yoghurt, ice cream, smoothies, and custard during acute illness
An otolaryngologist (ENT) is the appropriate specialist for definitive drainage, airway assessment, and decisions about quinsy versus interval tonsillectomy. Emergency referral is essential when there is severe trismus, drooling, stridor, suspicion of deep-neck infection, or failure to improve within 24 hours of antibiotic therapy.
01Recurrent peritonsillar abscess (9-22%) — addressed with interval tonsillectomy.
02Parapharyngeal or retropharyngeal abscess from posterior extension — diagnose with CT and treat with surgical drainage and broad-spectrum antibiotics.
03Lemierre syndrome (internal jugular vein thrombophlebitis with Fusobacterium necrophorum) — suspect when high fever and rigors persist despite drainage; CT and blood cultures confirm.
04Airway obstruction from massive swelling or bilateral abscess — managed with urgent ENT and anaesthesia, sometimes tracheostomy.
05Descending necrotising mediastinitis with mortality 15-40% — extremely rare but life-threatening; needs urgent thoracic surgery.
06Carotid artery erosion or pseudoaneurysm — rare but catastrophic; presents with sentinel bleed and shock.
Superior peritonsillar abscess (classic)Pus collects in the upper pole between the tonsil capsule and the soft palate. Most common location (around 90% of cases). Presents with the classic bulge above the tonsil, uvular deviation, and trismus. Easily accessible for needle aspiration.
Inferior peritonsillar abscessPus in the lower pole between the tonsil and the tongue base. Less obvious on direct inspection; severe odynophagia and referred otalgia predominate. Imaging is often needed for diagnosis.
Peritonsillar cellulitisDiffuse inflammation of the peritonsillar tissues without a drainable pus collection. Symptoms are similar but milder; needle aspiration returns no pus, and intravenous antibiotics alone are usually effective. Up to 30% progress to frank abscess if untreated.
Bilateral peritonsillar abscessRare (5-7% of cases). Both peritonsillar spaces are involved with symmetrical swelling and uvular oedema rather than deviation. High risk of airway compromise; usually requires bilateral drainage.
Recurrent peritonsillar abscessRepeat abscess after initial drainage in 9-22% of patients. Strong indication for interval tonsillectomy 4-6 weeks after the acute episode.
Living with Peritonsillar Abscess
Timeline
Pain and trismus improve markedly within 24-48 hours of drainage. Most patients return to school or work after 5-7 days. Antibiotics are completed over 10 days. Full energy and appetite return over 2-3 weeks. Interval tonsillectomy, if planned, is scheduled 4-6 weeks after the acute episode when inflammation has fully resolved.
Lifestyle
01Stop smoking permanently to reduce recurrence risk.
02Stay well hydrated during throat infections with at least 2 L per day of fluids.
03Use warm saline gargles 4-6 times daily during sore throat episodes.
04Complete the full prescribed antibiotic course even if symptoms resolve early.
05Avoid sharing utensils, cups, or close contact with people who have streptococcal tonsillitis.
06Treat dental infections promptly with appropriate dental review.
Daily management
01Take prescribed oral antibiotics at exact intervals for the full 10-day course.
02Gargle with warm salt water every 2-3 hours during waking hours.
03
Complementary approaches
Warm saline garglesFrequent warm salt-water rinses (every 2-3 hours) reduce local inflammation, soothe the pharynx, and may aid spontaneous drainage of small collections. Adjunct only, not a substitute for definitive treatment.
Choosing a doctor
Choose a centre with 24-hour ENT cover, anaesthetic support for shared-airway management, and access to contrast-enhanced CT. Ask about success rates of needle aspiration versus incision and drainage, and policy on interval tonsillectomy after recurrence.
A peritonsillar abscess, also called quinsy, is a pocket of pus that forms between the tonsil and the surrounding throat muscles, usually as a complication of bacterial tonsillitis. It causes severe one-sided throat pain, difficulty opening the mouth, muffled speech, fever, and a visible bulge that pushes the uvula to the opposite side.
How is peritonsillar abscess different from tonsillitis?▾▴
Tonsillitis is a bilateral infection of both tonsils causing sore throat, fever, and exudate but without trismus or uvular deviation. Peritonsillar abscess is a unilateral pus collection with severe one-sided pain, trismus, drooling, and a bulging soft palate that displaces the uvula.
What causes a peritonsillar abscess?▾▴
Most cases follow bacterial tonsillitis, with group A Streptococcus, Fusobacterium necrophorum, Prevotella, Peptostreptococcus, and Staphylococcus aureus identified on culture. Smoking, recurrent tonsillitis, immunocompromise, and dental infection raise the risk.
How is peritonsillar abscess treated?▾▴
Treatment combines drainage of pus by needle aspiration or incision under local anaesthesia, intravenous antibiotics covering streptococci and anaerobes (amoxicillin-clavulanate or clindamycin), intravenous fluids, analgesia, and a short course of corticosteroid to reduce swelling. Most patients improve within 24-48 hours.
Is needle aspiration or incision and drainage better?▾▴
Pooled randomized trials show needle aspiration and incision and drainage achieve comparable success rates of 87-95%. Needle aspiration is less invasive and preferred for cooperative adults; incision and drainage is used when aspiration is dry, recurrent, or in children.
Do I need a tonsillectomy after a peritonsillar abscess?▾▴
Tonsillectomy is offered after recurrent peritonsillar abscess or for patients with a history of recurrent tonsillitis. After a single episode without these features, observation is reasonable. Interval tonsillectomy is usually scheduled 4-6 weeks after the acute episode.
Can a peritonsillar abscess be treated with antibiotics alone?▾▴
Antibiotics alone may resolve peritonsillar cellulitis (inflammation without a drainable pus collection) but are usually inadequate for an established abscess. Definitive drainage is needed in most cases. Failure to drain leads to prolonged illness and risk of deep-neck-space extension.
How long does it take to recover from peritonsillar abscess?▾▴
Pain and trismus improve within 24-48 hours after drainage, and most patients are discharged on day 2-3. Antibiotics are completed over 10 days. Most return to school or work within 5-7 days and to full energy over 2-3 weeks.
Is peritonsillar abscess contagious?▾▴
The abscess itself is not contagious, but the underlying streptococcal infection that often precedes it is transmissible through respiratory droplets. Close contacts may develop sore throat and should be treated if streptococcal infection is confirmed.
Can children get peritonsillar abscess?▾▴
Yes, but it is uncommon under age 5. Most paediatric cases occur in adolescents. Children may need general anaesthesia for drainage because of inability to cooperate with bedside aspiration. Recurrence is an indication for tonsillectomy.
What is hot-potato voice?▾▴
Hot-potato voice is a muffled, thick speech pattern that sounds as if the speaker has a hot potato in the mouth. It results from soft-palate swelling reducing oral resonance. It is a hallmark of peritonsillar abscess and other deep oropharyngeal infections.
What is trismus?▾▴
Trismus is restricted mouth opening due to muscle spasm or inflammation around the jaw. In peritonsillar abscess it results from inflammation of the medial pterygoid muscle adjacent to the abscess. Interincisor distance under 2 cm strongly suggests deep peritonsillar or deep-neck infection.
Can peritonsillar abscess cause airway obstruction?▾▴
Severe or bilateral abscess can compromise the airway by mass effect and surrounding oedema, especially in children and patients with epiglottitis or Ludwig angina. Stridor, drooling, and the tripod position are red flags that require immediate airway assessment.
What is Lemierre syndrome?▾▴
Lemierre syndrome is septic thrombophlebitis of the internal jugular vein, usually caused by Fusobacterium necrophorum spreading from the oropharynx. It presents with persistent high fever, rigors, neck pain, and septic pulmonary emboli after a sore throat. Diagnosis is by neck CT with contrast and blood cultures.
What antibiotics treat peritonsillar abscess?▾▴
First-line is intravenous amoxicillin-clavulanate; alternatives include benzylpenicillin plus metronidazole, clindamycin for penicillin allergy, and piperacillin-tazobactam in severe or immunocompromised cases. Oral co-amoxiclav or clindamycin is given for 10 days once the patient is stable.
Will I need a CT scan?▾▴
CT is reserved for severe trismus preventing examination, suspected deep-neck-space extension, bilateral abscess, failed initial drainage, or recurrent presentation. Contrast-enhanced CT of the neck delineates the abscess and surrounding spaces and excludes Lemierre syndrome.
Is peritonsillar abscess dangerous?▾▴
With prompt drainage and antibiotics, mortality is under 0.5% in high-income healthcare. Delayed diagnosis can lead to deep-neck infection, airway obstruction, Lemierre syndrome, descending mediastinitis, or carotid erosion, with mortality rising to 15-40% in advanced cases.
Can peritonsillar abscess recur?▾▴
Recurrence rates are 9-22% after a single episode and are highest in patients with recurrent tonsillitis, smokers, and those under 30. Interval tonsillectomy 4-6 weeks after the acute episode prevents recurrence in over 95% of these patients.
Should I avoid smoking after peritonsillar abscess?▾▴
Yes. Smokers have approximately 3-4 times higher incidence and recurrence rates than non-smokers. Stopping smoking after a first episode reduces the risk of recurrence and improves overall throat health. Nicotine replacement and behavioural support are effective.
What is the difference between peritonsillar abscess and peritonsillar cellulitis?▾▴
Peritonsillar cellulitis is diffuse inflammation of the peritonsillar tissues without a drainable pus collection; needle aspiration is dry and intravenous antibiotics alone suffice. Peritonsillar abscess has a discrete pus collection that requires drainage. Up to 30% of cellulitis progresses to abscess if untreated.
Fever, usually 38.5-40 °C, with rigors, myalgia, and malaise.
07Swollen, tender cervical lymphadenopathy, especially in the jugulodigastric chain on the affected side.
08Halitosis (foetor oris) from anaerobic infection.
09Visible bulging of the soft palate above and lateral to the tonsil with deviation of the uvula to the opposite side.
10Neck stiffness or torticollis tilting the head toward the affected side to relieve traction on inflamed muscles.
early warning signs
•Sore throat lasting more than 5 days despite oral antibiotics or worsening after 48 hours of treatment
•Asymmetry between the two sides of the throat or progressively more pain on one side
•Early trismus (subtle limitation of mouth opening) with one-sided sore throat
•Difficulty swallowing saliva and reluctance to drink fluids in a febrile adolescent
•Otalgia on the same side as the sore throat without ear examination findings
● emergency signs
•Stridor, drooling, sitting-forward posture, or tripod position suggesting impending airway obstruction — requires immediate airway management
•Inability to swallow saliva with rapidly progressive trismus and toxic appearance
•Spreading neck swelling, induration, or crepitus suggesting deep-neck-space infection or necrotising fasciitis
•High fever, rigors, hypotension, and tachycardia consistent with septic shock or Lemierre syndrome
•Sudden severe haemorrhage from the throat suggesting erosion into the carotid sheath
03
Intraoral or transcutaneous ultrasoundDifferentiates abscess from cellulitis when clinical examination is limited; guides drainage in obese or trismic patients
04
Contrast-enhanced CT of the neckVisualizes the abscess size and location, excludes deep-neck-space extension, mediastinitis, or internal jugular thrombophlebitis
05
Full blood count, C-reactive protein, electrolytes, urea, creatinineConfirms systemic inflammatory response, hydration status, and renal function before antibiotic dosing
06
Throat swab and pus cultureIdentifies the causative organism and guides targeted antibiotic therapy
07
Blood cultures (when systemically septic)Identifies bacteraemia and helps detect Lemierre syndrome with Fusobacterium necrophorum
Outlook
Outcomes are excellent with prompt drainage and appropriate antibiotics: more than 90% of patients are afebrile and tolerating oral intake within 48 hours of treatment, and most are discharged on day 2-3. Recurrence rates after initial successful drainage are 9-22% in long-term follow-up; risk is highest in patients with a history of recurrent tonsillitis, smokers, and patients under 30 years old. Interval or quinsy tonsillectomy prevents recurrence in over 95% of these patients. Complications include parapharyngeal or retropharyngeal abscess, mediastinitis, jugular vein thrombophlebitis (Lemierre syndrome), airway obstruction, aspiration pneumonia, and rarely carotid blowout. Mortality is under 0.5% in high-income healthcare systems but rises significantly when diagnosis is delayed or in immunocompromised patients. Untreated infection can progress to airway compromise or descending necrotising mediastinitis with mortality of 15-40% even with modern care.
non-modifiable
Peritonsillar abscess peaks in adolescence and young adulthood when tonsillar tissue is most active. Incidence falls sharply after age 40.
Smoking (active or passive)modifiable
Active smoking increases incidence approximately 3-4 fold; secondhand smoke exposure also elevates risk in children and adolescents.
Recurrent tonsillitismodifiable
Patients with three or more episodes of bacterial tonsillitis per year have approximately 4× greater lifetime risk of peritonsillar abscess.
Male sexnon-modifiable
Men are affected approximately 1.5-2× more often than women in published series, partly reflecting smoking prevalence.
Immunocompromisemodifiable
HIV, poorly controlled diabetes, immunosuppressive therapy, and steroid use predispose to bacterial spread; abscess in these patients is often more aggressive and may be polymicrobial with unusual organisms.
Recent dental infectionmodifiable
Periapical and periodontal abscesses can extend to neck spaces; poor oral hygiene is a co-factor in some series.
Winter seasonenvironmental
Incidence rises 30-50% in winter months in temperate climates, paralleling the seasonal peak of streptococcal pharyngitis.
Bland warm soups once swallowing improves
•Protein-rich liquids (milk, plant-based shakes) to maintain nutrition
foods to avoid
•Hot and spicy foods that aggravate pharyngeal pain
•Acidic juices (orange, grapefruit) that sting raw mucosa
•Rough or sharp foods (toast, crisps) until swelling resolves
•Alcohol while on antibiotics and during convalescence
choosing the right hospital
01Emergency department with 24-hour ENT availability
02Airway expertise (anaesthesia, ICU) for severe cases
03Contrast-enhanced CT scanning available out of hours
04Microbiology laboratory for aerobic and anaerobic culture
05Inpatient capacity for 24-48 hour observation
Essential facilities
Tertiary ENT centresEmergency departments with on-call ENTPaediatric otolaryngology servicesInfectious disease units for deep-neck infectionIntensive care for airway-threatening cases
Maintain fluid intake of at least 2 L daily, including electrolyte drinks if appetite is poor.
04Monitor temperature twice daily for the first week and seek urgent review if it rises again.
05Use paracetamol and ibuprofen for pain in maximum recommended doses.
06Avoid smoking and second-hand smoke during recovery.
Exercise
Bed rest during acute illness; light walking once afebrile. Avoid strenuous exercise and contact sport until at least one week after discharge to reduce the risk of post-drainage bleeding and to allow full hydration recovery.